Chapter Overview



Chapter 12

Environmental Emergencies

Unit Summary

After students complete this chapter and the related coursework, they will have learned the proper assessment and management of general and specific types of environmental emergencies, including hypothermia, local cold injuries such as frostbite, and heat exposure illnesses such as heatstroke. They will also learn the associated signs and symptoms and emergency treatment for drowning, submersion, and lightning injuries.

National EMS Education Standard Competencies

Trauma

Uses simple knowledge to recognize and manage life threats based on assessment findings for an acutely injured patient while awaiting additional emergency medical response.

Environmental Emergencies

Recognition and management of:

• Submersion incidents (p 258)

• Temperature-related illness (pp 254–258)

Knowledge Objectives

1. Describe the signs and symptoms of a patient experiencing heat cramps. (p 254)

2. Describe the treatment of a patient experiencing heat cramps. (p 254)

3. Describe the signs and symptoms of a patient experiencing heat exhaustion. (p 254)

4. Describe the treatment of a patient experiencing heat exhaustion. (p 254)

5. Describe the signs and symptoms of a patient experiencing heatstroke. (p 255)

6. Describe the treatment of a patient experiencing heatstroke. (p 255)

7. Describe the signs and symptoms of a patient experiencing frostbite. (pp 256–257)

8. Describe the treatment of a patient experiencing frostbite. (pp 256–257)

9. Describe the signs and symptoms of a patient experiencing hypothermia. (p 257)

10. Describe the treatment of a patient experiencing hypothermia. (p 257)

11. Discuss the relationship between hypothermia and cardiac arrest. (p 258)

12. Describe the signs and symptoms of a patient who sustained a submersion injury. (pp 258, 260)

13. Describe the treatment of a patient who sustained a submersion injury. (pp 258, 260)

14. Describe the signs and symptoms of lightning injuries. (p 260)

15. Describe the treatment of lightning injuries. (p 260)

Skills Objectives

1. Demonstrate patient assessment on a patient who has sustained an injury or illness from exposure to heat, exposure to cold, or submersion. (p 253)

2. Demonstrate cooling a patient who has experienced exposure to heat. (pp 254–255)

3. Demonstrate treating a patient who has experienced exposure to cold. (pp 256–257)

4. Demonstrate treating a patient who has a submersion injury. (p 260)

5. Demonstrate treating a patient who has a lightning injury. (p 260)

Readings and Preparation

Review all instructional materials, including Emergency Medical Responder, Fifth Edition, Chapter 12, and all related presentation support materials.

• Review any local protocols on treatment of medical emergencies.

Support Materials

• Lecture PowerPoint presentation

• Equipment needed to perform the psychomotor skills presented in this chapter.

• A variety of pictures showing stages of frostbite, heatstroke, hypothermia, and other environmental emergencies

Enhancements

• Direct students to visit the companion web site to the Fifth Edition at EMR. for online activities.

• If activities in your local area create a risk for certain environmental emergencies, contact local providers for information and/or guest speakers (eg, personnel from a hyperbaric chamber, local experts in heat or cold injuries).

• Contact a local EMS agency or public health department for information on any preventive health campaigns with which your students could become involved (eg, pool safety, water hazards).

Teaching Tips

• Some students may have phobias or be uncomfortable with the idea of drowning, lightning, or some other type of environmental injury. Make sure to take time to recognize and address students’ fears.

Unit Activities

Writing assignments: Have students research the signs, symptoms, and treatment for heatstroke, heat exhaustion, and heat cramps. Ask students to write an essay about their findings.

Group activities: Break students into two groups. Pass around cold packs to the first group and heat packs to the second group. Have students hold the packs in their hands and ask them to observe how their body responds. Have each group present its findings to the other group.

Medical terminology review: Create a terminology Jeopardy game with questions that include important medical terms and terms about environmental injuries and treatment. There are Jeopardy game templates available on the Internet.

Pre-Lecture

You are the Provider

“You are the Provider” is a progressive case study that encourages critical thinking skills.

Instructor Directions

1. Direct students to read the “You are the Provider” scenario found throughout Chapter 12.

2. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions.

3. You may also use this exercise as an individual activity and ask students to turn in their comments on a separate piece of paper.

Lecture

I. Introduction

A. When a person is exposed to excess heat, the body’s mechanisms for regulating temperature can be overwhelmed, resulting in:

1. Heat cramps

2. Heat exhaustion

3. Heatstroke

B. Exposure to cold environments may result in conditions such as frostbite or hypothermia.

C. Unintentional exposure to water can lead to submersion and drowning.

II. Patient Assessment for Environmental Emergencies

A. Your approach to a patient who has signs and symptoms of an environmental emergency should follow the patient assessment sequence.

1. Review the dispatch information to help you decide on possibilities for the patient’s problem.

2. Asses the scene to determine safety issues for you and the patient.

3. As you perform the primary assessment:

a. Try to form an impression of the patient’s problem.

b. Determine the patient’s responsiveness.

c. Introduce yourself.

d. Check the patient’s ABCs.

e. Acknowledge the patient’s chief complaint.

4. Usually, it is best to collect a medical history on the patient experiencing a medical problem before you perform a secondary assessment.

a. The SAMPLE history format will help you secure the necessary information:

i. Signs/symptoms

ii. Allergies

iii. Medications

iv. Pertinent past history

v. Last oral intake

vi. Events associated with or leading to the illness or injury

5. The secondary patient assessment focuses on the areas related to the patient’s current illness.

a. The patient may not always be aware of all the various aspects of his or her problem.

b. Obtain the patient’s vital signs.

6. Monitor the patient through the use of ongoing reassessment if the arrival of additional EMS personnel is delayed.

III. Exposure to Heat

A. Heat cramps

1. Heat cramps are involuntary spasms of the muscles.

2. They often occur after exercise, especially in hot weather.

3. The exact cause of heat cramps is not known, but is thought to be related partly to the change in the electrolyte levels that occurs during exercise and partly to the dehydration that accompanies exercise or working in a hot environment.

4. Heat cramps most commonly occur in the leg or calf muscles.

5. When abdominal cramps occur, it may appear that the patient is having an acute abdominal problem.

6. Treatment of heat cramps

a. Move the patient to a cool place.

b. Have the patient lie down in a comfortable position.

c. Give the patient water to drink.

d. If the cramps do not disappear, arrange to have the patient transported to an appropriate medical facility.

B. Heat exhaustion

1. Heat exhaustion occurs when a person is exposed to temperatures higher than 80ºF (27ºC), usually in combination with high humidity.

2. It can also occur as the result of vigorous exercise at lower temperatures.

3. Signs and symptoms of heat exhaustion include:

a. Profuse sweating

b. Lightheadedness

c. Dizziness

d. Nausea

e. Weak pulse

f. Low blood pressure

4. Predisposing factors may make some people more susceptible to heat-related illnesses.

a. Very young or old age

b. Preexisting medical conditions

c. Certain medications

d. High ambient temperatures

e. High humidity

5. Treatment of heat exhaustion

a. Move the patient to a cooler place and treat him or her for shock.

b. Unless the patient is unconscious, nauseated, or vomiting, give fluids by mouth.

c. Monitor the ABCs.

d. Arrange transport to a medical facility.

C. Heatstroke

1. Heatstroke occurs when the body is subjected to more heat than it can handle and the normal mechanisms for getting rid of the excess heat are overwhelmed.

2. The patient’s body temperature rises until it reaches a level at which brain damage occurs.

a. Without prompt and proper treatment, a patient with heatstroke will die.

3. Signs and symptoms include:

a. Flushed, dry skin that feels hot to the touch

b. Semiconsciousness or unconsciousness

c. Internal temperatures as high as 106°F (41.1°C)

4. Treatment for heatstroke

a. Maintain the patient’s ABCs.

b. Remove the patient from the hot environment and into a cool place as soon as possible.

c. Remove the patient’s clothes, down to the underwear.

d. Soak the patient with water.

e. If the patient is conscious and not nauseated, administer small amounts of cool water.

f. Arrange for rapid transport.

IV. Exposure to Cold

A. Frostbite

1. Frostbite can result when exposed parts of the body are exposed to a cold environment.

a. Exposed body parts actually freeze.

2. Body parts most susceptible to frostbite:

a. Face

b. Ears

c. Fingers

d. Toes

3. Depending on the temperature and wind velocity, frostbite can occur in a short period.

4. People weakened by old age, medical conditions, exhaustion, or hunger are most susceptible to frostbite.

5. Superficial frostbite (frostnip)

a. The affected body part becomes numb and then turns a bright red color.

b. Eventually the area loses its color and changes to pale white.

c. There may be a loss of feeling and sensation in the injured area.

d. Treatment

i. Warming a superficial frostbitten area or part must be done quickly and carefully.

ii. Do not try to warm a frostbitten area by rubbing it with your hands or a blanket.

iii. Treat the frostbitten patient for shock.

6. Deep frostbite

a. The patient’s skin will be white and waxy.

b. The skin may be firm or frozen.

c. Swelling and blisters may be present.

d. If the skin has thawed, it may appear flushed with areas of purple and white or it may be mottled and cyanotic.

e. Treatment

i. Remove any jewelry the patient is wearing and cover the extremity with dry clothing or dry dressings.

ii. Do not break blisters, rub the injured area, apply heat, or allow the patient to walk on an affected lower extremity.

iii. Provide prompt transport to a medical facility.

B. Hypothermia

1. Hypothermia occurs when a person’s body temperature drops to less than 95ºF (35ºC).

2. In hypothermia, a person’s body is not able to produce enough energy to keep the internal (core) body temperature at a satisfactory level.

3 People with inadequate or wet clothing and those weakened by illness are most susceptible to hypothermia.

4. Signs and symptoms include:

a. Feeling cold

b. Shivering

c. Decreased level of consciousness

d. Sleepiness

e. Lack of coordination

f. Mental confusion

g. Slowed reactions

h. Unconsciousness

5. Treatment of hypothermia

a. Move the patient to a warm location.

b. Remove wet clothing.

c. Place warm blankets over and under the patient.

d. If the patient is conscious, give warm fluids to drink.

e. If you do not have access to a building, move the patient into a heated vehicle.

f. If transport is delayed or extended, you may need to use your own body heat to warm the patient.

g. Handle the patient gently.

h. Hypothermic patients must be examined by a physician.

6. Cardiac arrest and hypothermia

a. If the patient’s body temperature falls to less than 83°F (28°C), the heart may stop and you will need to begin cardiopulmonary resuscitation (CPR).

b. Always start CPR and use an automated external defibrillator, if available, on hypothermic patients even if you believe they have been “dead” for several hours.

c. Hypothermia patients should never be considered dead until they have been warmed in an appropriate medical facility.

V. Drowning and Submersion

A. Each year in the United States, more than 3,000 people die from drowning.

B. Drowning is the second leading cause of injury and death among children 1 to 14 years.

1. Alcohol consumption is a contributing factor in many cases of drowning in teenagers and adults.

C. Drowning is defined as suffocation because of submersion in water or in other fluids.

1. Submersion injuries result from being beneath the surface of water or another liquid.

2. Likely locations of drowning include:

a. Streams

b. Lakes

c. Swimming pools

d. Hot tubs

e. Wading pools

f. Public fountains

g. Storm drain ponds

3. The following hazards for drowning in infants and young children are present in every house:

a. Bathtubs

b. Toilets

c. Mop buckets

4. Young children can drown in liquids as shallow as 6".

D. The process of drowning progresses through several stages.

1. Usually the initial stage is panic as the person realizes that something is wrong.

2. In other instances, the person:

a. Becomes fatigued, injured, cold, or entangled in seaweed or kelp

b. Experiences a loss of orientation

c. Becomes ill

3. The feeling of panic produces an inefficient breathing pattern.

a. If a swimmer is not able to take in full breaths, buoyancy is lost and exhaustion sets in.

b. Small quantities of water reaching the larynx cause a spasm of the larynx (laryngospasm), which makes it hard or impossible to breath.

c. If this cycle of panic is not corrected, respiratory and cardiac arrest can result.

4. Signs and symptoms of submersion injury include:

a. Coughing

b. Vomiting

c. Difficulty breathing

d. Respiratory arrest

e. Cardiac arrest

f. Broken bones or spinal injuries

g. Hypothermia

E. Treatment of submersion injuries

1. Assess scene safety.

a. If the patient is still in the water, do not exceed the limits of your training in an attempt to rescue him or her.

b. Call for additional help if needed.

c. If there is evidence of trauma and you need to move the patient, protect the spine from further injury.

2. Perform a primary assessment.

3. As soon as possible, perform a secondary assessment to check for other injuries.

a. Correct any airway, breathing, and circulation problems.

b. Begin CPR if indicated.

c. If the patient is breathing adequately, administer high-flow oxygen.

d. As soon as the ABCs are stabilized, dry the patient.

e. Cover the patient with towels or blankets to help preserve body temperature.

4. Obtain the patient’s medical history from the patient if possible, or from any family members present.

5. Perform regular reassessments.

6. All patients who have sustained a submersion injury should be examined by a physician.

F. Cold water drowning

1. You should begin CPR on a drowning victim as long as the patient does not exhibit the definitive signs of death.

2. When a person is submerged in cold water, a protective mechanism called the mammalian diving reflex may be activated.

a. This reflex slows the heart rate and metabolic rate and decreases the body’s demand for oxygen.

3. When you encounter a person who has been submerged in cold water even for an extended period, CPR should be started and continued until the person has been delivered to an appropriate medical facility.

VI. Other Environmental Emergencies

A. Lightning injuries

1. The electrical injury resulting from a lightning strike can cause cardiac irregularities or cardiac arrest.

2. Treat patients who have been struck by lightning by supporting the airway, breathing, and circulation.

a. Oxygen administration, defibrillation, and CPR may be needed for some patients.

b. Patients must be transported to an appropriate medical facility.

3. Lightning injuries can also cause electrical burns.

a. This type of burn is mainly internal, so the extent of burn damage will not be visible immediately after the injury occurs.

B. Bites and stings

1. Bites and stings are sometimes classified as environmental injuries or discussed under the topic of poisoning.

2. In this book, they are discussed in Chapter 10: Poisoning and Substance Abuse.

VII. Summary

A. Your approach to a patient who has experienced an environmental emergency should follow the patient assessment sequence.

B. Heat cramps are caused by electrolyte imbalance and dehydration. They usually involve muscles in the calf, leg, or abdomen. Usually the cramps disappear with rest and the administration of water.

C. A person experiencing heat exhaustion sweats profusely and becomes light-headed, dizzy, and nauseated. Predisposing factors may make some people more susceptible to heat-related illnesses.

D. Heatstroke results when a person has been in a hot environment for a long period, overwhelming the body’s sweating mechanism. The patient’s body temperature rises until it reaches a level at which brain damage occurs.

E. The body parts most susceptible to frostbite are the face, ears, fingers, and toes. Warming the frostbitten part must be done quickly and carefully.

F. Hypothermia occurs when a person’s body is not able to produce enough heat to keep the internal (core) body temperature at a satisfactory level.

G. The initial signs of hypothermia include feeling cold, shivering, decreasing level of consciousness, and sleepiness. Signs of increasing hypothermia include a lack of coordination, mental confusion, and slowed reactions.

H. Hypothermic patients should never be considered dead until they have been warmed in an appropriate medical facility.

I. Drowning can occur in a variety of settings around a home and outdoors. Signs and symptoms of a submersion injury include coughing, vomiting, difficulty breathing, respiratory arrest, cardiac arrest, and trauma.

J. Lightning injuries are caused by a powerful jolt of electrical current that passes through part of the body. They may cause irregular heart rhythms or cardiac arrest. They also cause an electrical type of burn that damages tissue within the body.

Post-Lecture

This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities.

Assessment in Action

This activity allows the student an opportunity to analyze an emergency care scenario and develop responses to critical-thinking questions. This scenario is designed to assist students in gaining a further understanding of issues surrounding environmental emergencies.

Instructor Directions

1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the end of Chapter 12.

2. Direct students to read and individually answer the quiz questions at the end of the scenario. Facilitate a class review and discussion of the answers, allowing students to correct their responses as needed. Use the quiz question answers noted here to assist in building this review.

3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper.

Answers to Assessment in Action Questions

1. Answer: B Alcohol

2. Answer: C Roll the patient to one side to allow water to drain out of the mouth.

3. Answer: B Laryngospasm

4. Answer: C A person wearing cotton jeans and a t-shirt on a rainy, windy 60oF (16oC) day

5. Answer: D Hypothermia

6. Answer: C The water is cold.

7. Answer: A Skin remains soft.

8. Answer: Usually the initial stage is panic as the person realizes that something is wrong, such as a strong current that is overpowering. In other instances, the person may become fatigued, injured, cold, or entangled in seaweed or kelp; experience a loss of orientation; or become ill. The feeling of panic produces an inefficient breathing pattern. If a swimmer is not able to take in full breaths, buoyancy is lost and exhaustion sets in as the person struggles to stay on the surface of the water. Small quantities of water reaching the larynx cause a spasm of the larynx (laryngospasm), which makes it hard or impossible to breathe. If this cycle of panic is not corrected, respiratory and cardiac arrest can result.

9. Answer: The mammalian diving reflex slows the heart rate and metabolic rate and decreases the body’s demand for oxygen, allowing the body to survive for long periods in cold water submersion.

10. Answer: The initial signs of hypothermia include feelings of being cold, shivering, decreasing level of consciousness, and sleepiness. Shivering is the body’s attempt to produce more heat. As hypothermia progresses, shivering stops. Signs of increasing hypothermia include a lack of coordination, decreased level of consciousness and mental confusion, and slowed reactions. As the body’s temperature drops to less than 90ºF (32ºC), the patient will lose consciousness. Without treatment and warming to reverse the downward trend in body temperature, the patient will eventually die.

Lesson Review

A. Define heat cramps. (Lecture III-A)

B. List the signs and symptoms of heat exhaustion. (Lecture III-B)

C. What is the cause of heatstroke? (Lecture III-C)

D. Which types of people are the most susceptible to frostbite? (Lecture IV-A)

E. What is the treatment for hypothermia? (Lecture IV-B)

F. What are common hazards for drowning in infants and young children that are present in every house? (Lecture V-C)

G. What is the treatment for lightning injuries? (Lecture VI-A)

Assignments

A. Complete all the Student Workbook activities for Chapter 12.

B. Review all materials from this lesson and be prepared for a lesson quiz to be administered (date to be determined by the instructor).

C. Read Chapter 13: Bleeding, Shock, and Soft-Tissue Injuries for the next class session.

Unit Assessment Keyed for Instructors

1. Which condition results from the body’s normal cooling mechanisms becoming overwhelmed?

A. heatstroke

B. heat cramps

C. heat exhaustion

D. frostbite

Answer: A

p 255

2. Which of the following is not usually a sign of heatstroke?

A. high body temperature

B. sweating

C. dry skin

D. hot and red skin

Answer: B

p 255

3. What is the first step in treating a patient with heatstroke?

Answer: Move the patient out of the hot environment.

p 255

4. Your patient has been outside for an extended period and now has deep frostbite on her fingers. You should expect her skin to be:

A. white and waxy.

B. frozen.

C. swollen.

D. all of the above.

Answer: D

p 256

5. Which mechanism is used to generate body heat during hypothermia?

Answer: Shivering

p 257

6. At what core body temperature does the hypothermic patient lose consciousness?

Answer: 90°F (32°C)

p 257

7. The treatment of the hypothermic patient who is alert and responsive includes all of the following except:

A. removal of all of the patient’s wet clothing.

B. actively rewarming the patient during transport.

C. giving the patient plenty of cool liquids to drink.

D. providing care for shock and providing oxygen.

Answer: C

p 257

8. If transport is delayed while you are treating a hypothermic patient in a cold environment with no warm environment nearby, what can you do to keep the patient warm?

Answer: Use your own body heat to warm the patient. Wrap blankets around yourself and the patient or get into a sleeping bag with the patient to use your body heat to start the warming process.

p 257

9. Each year in the United States, more than 3,000 people die from:

A. heat exhaustion.

B. hypothermia.

C. drowning.

D. lightning injuries.

Answer: C

p 258

10. What is the initial stage in the drowning process?

Answer: Panic as the person realizes that something is wrong

p 258

Unit Assessment

1. Which condition results from the body’s normal cooling mechanisms becoming overwhelmed?

A. heatstroke

B. heat cramps

C. heat exhaustion

D. frostbite

2. Which of the following is not usually a sign of heatstroke?

A. high body temperature

B. sweating

C. dry skin

D. hot and red skin

3. What is the first step in treating a patient with heatstroke?

4. Your patient has been outside for an extended period and now has deep frostbite on her fingers. You should expect her skin to be:

A. white and waxy.

B. frozen.

C. swollen.

D. all of the above.

5. Which mechanism is used to generate body heat during hypothermia?

6. At what core body temperature does the hypothermic patient lose consciousness?

7. The treatment of the hypothermic patient who is alert and responsive includes all of the following except:

A. removal of all of the patient’s wet clothing.

B. actively rewarming the patient during transport.

C. giving the patient plenty of cool liquids to drink.

D. providing care for shock and providing oxygen.

8. If transport is delayed while you are treating a hypothermic patient in a cold environment with no warm environment nearby, what can you do to keep the patient warm?

9. Each year in the United States, more than 3,000 people die from:

A. heat exhaustion.

B. hypothermia.

C. drowning.

D. lightning injuries.

10. What is the initial stage in the drowning process?

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